state lifo an welfare agency department of health …

STATE OF CALIFORNIA-HEALTH AND WELFARE AGENCY PETE WILSON, Governor

DEPARTMENT OF HEALTH SERVICES714/744 P StreetP.O. BOX942732Sacramento, CA 94234-7320(916) 657-2941

Januar 16, 199616, 1996

MEDI-CAL ELIGIBILITY PROCEDURES MANUAL LETTER NO.: 155

TO: All Holders ofthe Medi-Cal Eligibility Procedures Manual

Enclosed are revised procedures for Article 15A-Identifying and CodingCoverage (OHC), and Article 15H-Health Insurance Premium Payment (HIPP) Program.

Other Healthogram.Pr

Procedures Revision

Article 15A

Description

This section provides information and proceidentifying, reporting, and coding of OHC.

This section provides information and proceto the HIPP and Employer Group Health Plan.

ures regardingproced

ures pertainingprocedPlan.

Article 15H

Filing Instructions:

Remove Pages Insert Pages

Article 15APages 15A-1 through 15A-15

Article 15HPages 15H-1 through 15H-3

Article 15APages 15A-1 through 15A-19

Article 15HPages 15H-1 through 15H-4

Ifyou have any questions concerning this article, please direct them toLea Golowski-Shalabi ofmy staff at (916) 654-5689.

Sincerely,

Original signed by

FranK S. Martucci, ChiefMedi-Cal Eligibility Branch

Enclosures

MEDI-CAL ELIGIBILITY PROCEDURES MANUAL

15A-IDENTIFYING, REPORTING AND CODING OTHER HEALTH COVERAGE (OHC)

This section provides information and procedures regarding identifying, reporting and coHealth Coverage (OHC). Eligibility workers code OHC on the Medi-Cal Eligibility Data Systerissue the Health Insurance Questionnaire (DHS 6155, revision date 2/90 or later) during eaand redetermination interview when applicant or beneficiary responds with a positive answeHealth Coverage Question on the Aid to Families with Dependent Children (AFDC) StateSupporting Eligibility for Assistance form (SAWS 2) or Statement of Facts form (MC 210). Fois used by county Welfare Offices to report Other Health Coverage to the Department of Health(DHS) for inclusion on the Health Insurance System (HIS).

mg of Other(MEDS) andapplication

to the Otherent of FactsForm DHS 6155Health Services

1. Background and Overview

The Department of Health Services is responsible for ensuring that Medi-Cal is the payor of lastresort for medical care used by Medi-Cal eligibles in accordance with State Statute Welfare andInstitutions Code Section 14124.90 and Federal Law (Section 1902(a) (25) of the Social SecurityAct). State laws (Welfare and Institutions Code, Sections 10020, 14000, 14003, 14005,14016.3, and 14024) require Medi-Cal beneficiaries to report and utilize these res urces beforeusing Medi-Cal. In instances where Medi-Cal has paid for a beneficiary's medical care first, theselaws also require the program to seek reimbursement from the responsible third party.

Since the Medi-Cal program is prohibited by federal law from paying for services which are coveredby the beneficiary's health insurance or health plan, in most instances, providers must bill theappropriate carrier before billing Medi-Cal. This is called cost avoidance. If a eneficiaryb isenrolled in a private Prepaid Health Plan/Health Maintenance Organization (PHP/HMO), thebeneficiary must be directed to his or her respective plan for treatment. Medi-Cal is not obligatedto pay for services available through a PHP/HMO plan when the beneficiary choises to seektreatment elsewhere.

In limited instances, a provider may bill the Medi-Cal program directly even though a beneficiaryhas OHC. The Department of Health Services then recovers the Medi-Cal payment from healthinsurance carriers using the State's automated billing system.

2.

Other Health Coverage (OHC) is defined as benefits for health related services or entitlements forwhich a Medi-Cal beneficiary is eligible under any private, group, or indemnification insuranceprogram, under any other State or federal medical care program, or under other contractual or legalentitlement.

3.

Insurance policies on the following list provide Other Health Coverage benefits. A He, th InsuranceQuestionnaire (DHS 6155, revision date 2/90 or later) must be completed to identify the healthcoverage source and scope of coverage for these insurance types.

a. Cancer-Only -- Policies that cover medical expenses related to cancer treatment only.

SECTION NO.: 50 761 MANUAL LETTER NO.: 155 DATE: 1-16-95 15A-1


b. CHAMPUS - The Civilian Health and Medical Program of the Uniformed Services pays forcare delivered by health providers to retired members and dependents of at active and retiredmembers of the Armed Forces under 65.

DentaLOnly -- Policies that cover expenses related to dental work.

Employment-related-Health-Insurance - Health insurance provided to employees and theirdependents. This could include health insurance through union membership ormembership in a national organization, fraternity or trust fund.

Employee RetirementlncomeSecurityAct (ERlSA)Trusts -- Any health insurance that isoffered through a trust fund operated by an employer under the authority of the U.S.Department of Labor (e.g., Carpenters, Pipefitters, Plumbers, Laborers, e.g.).

Group Health - Policies that provide health benefits to persons employed by or affiliatedwith an entity such as an employer, union, association or organization.

Health - Policies that cover hospital expenses, surgical expenses, routine medicalexpenses, or major medical.

Hospital -- Policies that cover expenses incurred during hospitalization.

Indemnity -- Policies that pay benefits in the form of cash payments. The e benefits arepaid to the insured instead of the provider or services.

Long term Care -- Policies that cover long term care expenses (e.g., custodial care,intermediate care, skilled nursing care).

Major Medical - Policies that cover medical expenses over and above those expensescovered by a basic benefit plan.

Medical Support From Absent Parents -- An absent parent may be required to providemedical insurance premium payments or be responsible for a portion of medical bills, or,if employed, may be required to include dependent children in the medical isurance planprovided by the employer.

MedicareSupplemental -- Policies which pay that portion of medical services whichMedicare does not pay.

PrepaidHealthPlan/HealthMaintenanceOrganization(PHP/HMO) -- Any Health benefitplan which provides a wide range of comprehensive health care servies for personsinsured by the policy or plan. Services are provided by plan designate providers atdesignated facilities.

Prescription -- Policies that cover prescribed drugs only.

Student Health -- Health insurance offered through an educational institution 1 for enrolledstudents.

Surgical -- Policies that cover surgery-related expenses only.

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r. Vision -- Policies that cover vision-related expenses only.

4. Types nf Coverage/Benefits and Situations When Other Health Coverage Should Not Be Reportad

The Department is specifically excluding the following coverage from the Other He Health Coverage(OHC) coding requirements and/or reporting on a revision date 2/90 or later.

a. Accident Benefits.

b. Automobile, Burial, and Life Insurance benefits.

c. Casualty Workers Compensation benefits.

d. Disability benefits.

e. Medicare (Title XVIII benefits).

f. Veteran's Administration (VA)benefits.

g. Coverage under a PHP/HMO which has contracted with the Department to provideMedi-Cal services to enrolled beneficiaries. (Medi-Cal Capitated Health Plans)

h. Coverage which is considered unavailable in the following situations:

(1) Coverage under any plan which is limited to a specific geographic service area andthe beneficiary lives outside that area or the plan requires use of specifiedproviders(s) and the beneficiary lives more than 60 miles or 60 minutes travel timefrom the specified provider(s). The beneficiary should be advised hat many ofthese plans cover out of area care in emergency situations. In this situation, thebeneficiary should provide OHC information to the emergency medic I provider sothat the provider may bill the plan before billing Medi-Cal.

(2) Coverage to which a child may be entitled when:

(a) The parent or guardian refuses to provide the necessary information dueto "good cause". Good cause shall be determined by the county. Goodcause exists when cooperation in securing medical support and payments,establishing paternity, and obtaining or providing informatiion concerningliable or potentially liable third parties from the absent p rent can bereasonably anticipated to result in serious physical or emotional harm tothe child for whom support is to be sought or to the parent or caretakerwith whom the child is living, or;

SECTION NO.: MANUAL LETTER NO.: 155 DATE: 1-16-96 15A-350 76 3


(b)

(c)

The absent parent cannot be located; and

The child is applying for Medi-Cal independently and would be in aseparate Medi-Cal Family Budget Unit (MFBU) from the custodial parentor guardian.

the child is applying for Medi-Cal independently and has no custodialparent or guardian. Adult children under Section 50014.

(d)

(3) Any coverage to which a child may be entitled in those instances where the childis applying for minor consent services in accordance with California AdministrativeCode, Title 22, Section 50147.1. The obligation to report and utilize OHC beforeusing Medi-Cal coverage is not enforced in this situation, since utilization of OHCwould violate the minor's right to confidentiality regarding his/her medicalservices.

5. County Responsibilities for Identifying Other Health Coverage (OHC)

a. Review Statement of Facts:

Review the applicant’s/beneficiary's MC 210 or CA 2 to determine if there is a positiveresponse to the question about having private health insurance or hospitalizationinsurance. If there is a positive response, go to procedure 6 (Reporting Other HealthCoverage Information). If there is no positive response to having private health insuranceon the MC 210 or CA 2, but the applicant/beneficiary is or was recently employed; hashealth insurance available through an employer or family member's employer, but has notenrolled; retired; serves or served in the military; or there is an absent pare it, proceed toprocedure (b). If there is no positive response after determining non availability ofinsurance, there is no need to complete the DHS 6155.

Section 4402, Omnibus Budget Reconciliation Act of 1990 (OBRA ’90) andates thatwhen it is cost effective, enrollment in an employer or group health plan is a condition ofMedicaid eligibility. Additionally, Section 50763(a)(1) California Code of Regulationsrequires that a Medi-Cal beneficiary shall apply for, and/or retain any available healthinsurance when no cost is involved.

b. Ask Questions to Identify OHC:

The following are key questions to ask applicants/beneficiaries for identifying theavailability of OHC:

SECTION NO.: 50765 MANUAL LETTER NO.: 155 DATE: 1-16-96 15A-4


TO EXPLORE WORK RELATED YESQUESTIONS

NO

Does your employer (or a familymember's employer) provide ahealth insurance plan?

If applicant/beneficiarycurrently HAS health insurancethrough an employer (or familymember's employer), completethe DHS 6155 with the currentinsurance information. Ifinsurance is available, butapplicant/beneficiary has notenrolled, complete the DHS6155 as an Employer GroupHealth Plan (EGHP) referral(refer to Section 15H forfurther information regardingEGHP).

Do not complete theDHS 6155.

Did your former employer (or afamily member’s employer)provide health insurancecoverage within the last three(3) years?

Complete the DHS 6155 andprovide the insurance beginningand ending dates.


Are you covered by yourunion’s health insurance plan?

Complete the DHS 6155 withthe health insuranceinformation.


Were you covered by yourunion's health insurance planwithin the last three (3) years?



Does an absent parent (or theabsent parent's employer)provide health insurancecoverage for you and/or yourchildren?

Complete the DHS 6155. Complete the CA2.1 MedicalSupport Referral packet. Donot complete the DHS 6155.

Did an absent parent (or theabsent parent's employer)provide health insurancecoverage for you and/or yourchildren within the last three(3) years?

Complete the DHS 6155 andprovide the insurance beginningand ending dates. Completethe CA2.1 Medical SupportReferral packet also.

Complete the CA2.1 MedicalSupport Referral packet. Donot complete the DHS 6155.

15A-5SECTION NO.: 5076 5 MANUAL LETTER NO.: 155 DATE: 1-16-96


Do you belong to any nationalorganization (e.g., Foresters,Eagles, etc.)? Do you havehealth insurance through theorganization?

Were you ever covered byinsurance through any nationalorganization (e.g. Foresters,Eagles, etc.) within the last (3)years?

IF THEAPPLICANT/BENEFICIARY ISOVER AGE 65, RETIRED, OR

DISABLED:

Do you have Medicarecoverage?





YES NO

If applicant/beneficiary ONLYhas Medicare coverage and NOadditional supplementaryinsurance plan, do notcomplete the DHS 6155.


Inform person they do not needOHC.


Inform person they do not needOHC.



Do you have health insurancein addition to Medicare (such asa Medigap or Medicaresupplement policy)?


Did you have health insurancein addition to Medicare withinthe last three (3) years?


Do you have health insurancethrough a pension or retirementplan?

Did you have health insurancethrough a pension or retirementplan within the last three (3)years?





TO EXPLORE OTHERINSURANCE POSSIBILITIES:

YES NO

Are you (or spouse or absentparent) enrolled in anyeducational program? If so, ishealth insurance availablethrough a student health plan?


Do not complete thDHS 6155.

Were you (or your spouse orabsent parent) enrolled in anyeducational program thatoffered health insurance withinthe last three (3) years?


Do not complete thDHS 6155.

Are you (or your spouse orabsent parent) in the military?DO NOT ASSUME THAT ONLYMEN HAVE SERVED IN THEMILITARY! If so, ask if militaryinsurance is available toapplicant/beneficiary and/orhis/her dependent(s). *

If the applicant/beneficiarycurrently has insuranceavailable through CHAMPUS,complete the DHS 6155 withthe health insuranceinformation. If insurance isavailable, but applicant/beneficiary has not enrolled,they should be instructed tocontact the California DefenseEnrollment Eligibility Reporting System (DEERS) Center at1-800-334-4162 to find outhow to go about enrolling forCHAMPUS benefits.


Were you (or your spouse orabsent parent) in the militarywithin the last three (3)years?*



*NOTE: Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) is a healthbenefits program for all seven uniformed services: the Army, Navy, Marine Corps, Air Force, CoastGuard Public Health Services, and National Oceanic and Atmospheric Administration. Coveredpersons include, but are not limited to:

•••

husbands, wives, and unmarried children of active-duty service members;retirees, their husbands or wives, and unmarried children; andunremarried husbands and wives and unmarried children of active duty or retired servicemembers who have died.

SECTION NO.: 5 0 765 MANUAL LETTER NO.: 155 DATE: 1-16-96 15A-7


TO EXPLORE OTHERINSURANCE POSSIBILITIES:

How have you paid for yourmedical care, prescriptions, andeyeglasses before now?

YES NO

If the applicant/beneficiaryindicates that these serviceshave or are covered byinsurance, complete theDHS 6155 with the healthinsurance information. Providethe ending insurance date ifapplicable.



Inform Applicant/Beneficiary:c.

(1) Reporting OHC Does Not Affect Medi-Cal Eligibility:

Inform applicants/beneficiaries that having and reporting OHC does not in any wayinterfere with their eligibility for or use of Medi-Cal benefits. Under federal lawMedi-Cal providers cannot deny care because a beneficiary has OH

(2) Do Not Advise Applicants/Beneficiaries To Drop OHC: except if they are onMedicare. Federal law requires us to inform them they do not need Medigapinsurance.

(3) Responsibility To Report And Apply For/Retain Employer Related Health CoverageBenefits:

Advise applicants/beneficiaries that federal law requires an individual, as acondition of Medi-Cal eligibility (in order to become or remain Medí-Cal eligible),to report employer related health insurance benefits available to h m/her. TheMedi-Cal program may pay the health coverage premiums if it is determinedcost-effective. Forward any information obtained from applicants/beneficiarieswith available employer related health benefits to the Department's HealthInsurance Premium Payment program for review of cost-effectiveness (refer toProcedure Manual, Article 15, Section 15H - Health Insurance Premium Payment Program).

(4) Responsibility To Report and Repay Medi-Cal For Insurance Payments Received:

(a) Forward reimbursement payments to:

Department of Health ServicesThird Party Liability BranchP.O. Box 671Sacramento, CA 95812-0671

(b) Beneficiaries should endorse checks from insurance carriers as follows:

• Name of Payee -- Party to whom the check is made payable.Signed either by the payee or their agent.

• Medi-Cal Identification Number of Beneficiary -- This may be adifferent person than the one who received the che< k.

• "For Deposit Only to Health Care Deposit Fund" - This will ensurethat the check will be properly applied to the State fund only.

(c) Beneficiaries must enclose with the check the date(s) of service, theprovider's name, and a daytime phone number where they can bereached.



(5) Confidentiality for Minor Consent Services:

Inform applicants/beneficiaries for minor consent services that Medi-Cal will notreport coverage nor bill private insurance carriers for such services provided tobeneficiaries under 21 years of age who are receiving minor consent services.When a restricted Minor Consent service card is issued to a minor, the card shouldnot be coded with an OHC code and OHC should not be reported n MEDS nor ona Health Insurance Questionnaire (DHS 6155, revision date 2/90 or later).

6.

County Responsibilities

a Issuance of Health Insurance Questionnaire (DHS 6155):

If the applicant/beneficiary indicates, either on the statement of facts of verbally, thathe/she has OHC or OHC is available through an employer, issue the Health InsuranceQuestionnaire (DHS 6155, revision date 2/90 or later). The applicant/beneficiarycompletes the DHS 6155 for the types of coverage outlined in Section 15a-3. (Types ofOther Health Coverage That Must be Reported) for all members of the family budget unitwith OHC. Help the applicant/beneficiary complete the form by asking if he/she has aninsurance identification card or other materials that may contain the necessaryinformation.

b. Completion And Accuracy of The DHS 6155:

Review the DHS 6155 for complete and accurate information.

Check the accuracy of information, particularly numbers. Be sure to check theSocial Security numbers, birth dates, policy/group numbers and phone numbers.If possible, attach a copy of the policy or copy of the insurance card .

Be sure the applicant’s/beneficiary’s name is listed, if covered, an i is spelledcorrectly.

Be sure the applicant’s/beneficiary's complete address is provided.

Be sure the insurance policy holder's name is provided and spelled correctly. Thisname may be different from the applicant’s/beneficiary's name.

Be sure the insurance policy holder's Social Security number is provided.

Provide complete and accurate eligibility worker information. This includes workernumber and telephone number, including area code.

Be sure the form is signed by the applicant/beneficiary and dated.

SECTION NO.: 507 6 5 MANUAL LETTER NO.: DATE: 15A-10155 1-16-96


c. Information On Scope of Coverage:

When reviewing a completed DHS 6155, check the scope of coverage field item 10, toinsure this information is reported. If the applicant/beneficiary does not know the scopeof coverage, request that he/she either review the policy or contact the insurance carrierto obtain this information. Scope of coverage information is essential in completing theDHS 6155 and must be provided. See Section 15A (8. Scope of Coverage) for moreinformation about scope of coverage.

Applicants/Beneficiaries With More Than One Insurance Policy:

If the applicant/beneficiary has more than one insurance policy, provide hi n/her with aDHS 6155 to be completed for each carrier. This includes policies covering singleservices, such as dental only coverage and vision services.

Code MEDS with the Appropriate OHC Code:

Please refer to Section 15A |7. Coding Other Health Coverage Information on TheMedi-Cal Eligibility Data System) for procedures.

Batching and Mailing DHS 6155:

Weekly, batch and mail the white copy of the DHS 6155 and any copies of healthinsurance identification cards or health insurance policies to:

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Department of Health ServicesHealth Insurance SectionP.O. Box 1287Sacramento, CA 95812-1287

Retain the Yellow Copy of the DHS 6155:

Retain a copy of the DHS 6155 form In applicant’s/beneficiary’s case file.

Send the Pink Copy to DA or Beneficiary:

Send the pink copy of the DHS 6155 to the DA's office in absent parent cases. Give it to thebeneficiary when it is not an absent parent situation (refer to Procedure Manual, Article 23,Medical Support Program).

Notify the Department of OHC Changes, Lapses in Coverage, or Changos in Scope ofCoverage.

When there has been a change to the scope of coverage, policy number, insurance billinginformation, or if the beneficiary’s OHC has lapsed, will lapse or change, update MEDS withthe corrected OHC code as needed. County Eligibility Workers (EWs) must send in correctedOHC information on a completed DHS 6155 or by calling the Department of Health ServicesHealth Insurance Section at 1-800-952-5294 when:

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(1) OHC has changed or is obtained;

(2) If reporting was not timely, but the county learns OHC has terminated or changedwithin 12 months prior to redetermination, ask beneficiary to complete a DHS 6155.Include the policy's termination date.

Inform beneficiaries that such Information must be reported to the county within en (10) daysfollowing the event.

Verification of Terminated Other Health Coverage

When a beneficiary Indicates that his/her OHC has terminated counties must obtainverification of OHC termination prior to removing the OHC code from Medi-Cal Eligibility DataSystem. Verification of OHC termination will be either.

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(1) A payroll or pension check stub which shows deductions for private health insurancehave ceased.

(2) An Explanation of Benefits from the insurance carrier showing the date the policyterminated.

(3) A termination letter from the insurance carrier and/or the employer showing the datethe policy terminated. If the letter indicates that continuation of medical benefits isavailable under Consolidated Omnibus Budget Reconciliation Act (COBRA) law, andthe beneficiary has a high cost medical condition, complete a Heal h InsuranceQuestionnaire (DHS 6155) In time to ensure that the policy can be continued andsend it to the Department’s Health Insurance Premium Payment Unit, P.O. Box 1287,Sacramento, CA 95812-1287. You may fax the DHS 6155 to (916) 322 -8778 or call1-800-952-5294 for more Information.

(4) Affidavit signed by the applicant/beneficiary stating he/she no longer has, or neverhad, OHC. This affidavit should also Include the date the policy terminated, if known.This affidavit should be used when an erroneous OHC code appears on a recipient’sMedi-Cal card after the Department conducts a data match with an insurancecompany.

k. High Cost Medical Condition

Medi-Cal eligibles who have a high cost medical condition should be referred to theDepartment's Health Insurance Premium Payment (HIPP) Program as specified above. Formore information about the HIPP Program, please refer to Section 15H of the Medi-CalEligibility Procedures Manual.

Employer Group Health Plan

Medi-Cal eligibles who have health insurance available through an employer [or a familymember's employer) should be referred to the Department's Employer Group Health Plan(EGHP) Program. For more information about the EGHP Program, please refer toSection 15H of Medi-Cal Eligibility Procedures Manual.

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SECTION NO.: 50 76 5 MANUAL LETTER NO.: 155 DATE: 1-16-96 15A-12


m. Notify the Department of OHC Termination

County eligibility workers must maintain a copy of the verification of OHC termination in thecase file as well as send a completed DHS 6155, showing the policy stop date, to theDepartment. For Supplemental Security Income/State Supplemental Payment cases, countyeligibility workers should delete the OHC code, attach a copy of the verification of OHCtermination of the completed copy of the DHS 6155 showing termination date and send bothdocuments to the Department.

Applicant/Beneficiary Responsibilities

(1) Report Current OHC Information to Counties:

Applicants/beneficiaries who have contractual or legal entitlement(s) to any health carecoverage must disclose this Information to the EW and must also provide specific healthinformation to the health care provider so that the provider may bill the liable third party.

(2) Report Available OHC to Counties:

Applicants/beneficiaries are required to report the availability of employer related healthbenefits.

(3) Report OHC Changes to Counties:

Applicants/beneficiaries who change, terminate, or obtain OHC must report such informationto the county within ten (10) days following the event.

(4) Report OHC Information to Providers:

Applicants/beneficiaries are required to provide current OHC billing information to theprovider at the time medical/dental services are received. This information shall includegroup number and baling office address. Willful failure to provide such informa ion may allowa provider to bill the beneficiary as a private pay patient.

7. Coding Other Health Coverage Information on the Medi-Cal Eligibility Data System

Eligibility Workers (EWs) must code Other Health Coverage (OHC) on the Medi-Cal Eligibility Data System (MEDS) at the time eligibility is determined or redetermined or at any time a beneficiary reportsa change in coverage.

a. Coding for No OHC:

When an applicant/beneficiary states that he/she does not have OHC, enter the letter code"N“ (No Other Health Coverage) on MEDS In the OHC field.


b.


Coding OHC:

The following Is a list of OHC codes and Instructions on how to determine the appropriateOHC code to place on MEDS. In order to determine the appropriate code, the followingquestions should be asked at the application and redetermination interview once theapplicant/beneficiary has reported OHC:

• Does your health insurance provide or pay for hospital in-patientcare?

• Does your health insurance pay for hospital outpatient care (e.g., emergency roomvisits, lab work, physical therapy)?

• Does your health insurance pay for doctor’s visits?

• Does your health insurance pay for prescriptions?

(1) Cost Avoidance OHC Codes:

If the applicant/beneficiary answers "yes" to at least three of the four questions listedabove, enter the appropriate cost avoidance code on MEDS. Cost avoidance codesto use are:

B Blue CrossC CHAMPUS *PrimeDEF GHIJKLPQSTUVW23 4568

PrudentialAetnaMedicare HMO RiskGeneral AmericanMutual of OmahaMetropolitan LifeJohn HancockKaiserDental Only PoliciesPHP/HMO, not otherwise specifiedEquicorBlue ShieldTravelersConnecticut General (CIGNA)Variable, any carriernot uniquely identifiedGreat West Life InsuranceProvident Life and AccidentPrincipal Financial GroupPacific Mutual Life InsuranceAlta Health Strategies, Inc.American Association of Retired Persons (AARP)New York Life Insurance

* Please note effective August 10,1994 CHAMPUS Standard or CHAMPUS Extra other health cove rage shouldbe coded with the OHC cost V'' ''.


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(2) Prepaid Health Plan/Health Maintenance Organization/Competitive Medical Plan(PHP/HMO/CMP) Other Health Coverage Codes:

If you determine from the questions above that an applicant/beneficiary recordrequires a cost avoidance code, ask the beneficiary: "Does your insurance orMedicare plan cover medical services only from specific facilities or providers?" If theapplicant/beneficiary answers “yes", enter a PHP/HMO/CMP code on MEDS. If theapplicant/beneficiary has Kaiser or CHAMPUS Prime, assign a "K" or "C" code. If theapplicant/beneficiary has Medicare HMO/CMP coverage, assign an “F" code. Codeany other PHP/HMO with a “P“, even though a unique cost avoidance code may existfor the carrier’s fee-for-service coverage. For example, should anapplicant/beneficiary have full coverage through Travelers Insurance, but coverageis limited to services provided by a specific group of professionals and hospitals, usethe PHP/HMO code "P" instead of the cost avoidance code "T".

Medi-Cal beneficiaries covered by Kaiser, CHAMPUS Prime, or otherPHP/HMO/CMPs must use designated facilities. Medi-Cal will reject bills for servicesprovided to beneficiaries with cards coded "K", ”C", "P", or ”F“. Medi-Cal will pay forservices only when the service is not a covered benefit under the designated plan.The service provider, however, must attach payment denial information from the planindicating the service is not a covered plan benefit. This will generate an override inthe claims payment system and allow payment to the provider.

Since the Department cannot obtain reimbursement from Kaiser, CHAMPUS Prime,or other PHP/HMO/CMPs, the importance of the "K", "C, “P”, or "F coding on theMedi-Cal card cannot be overemphasized.

Post Payment Recovery OHC Codes:

If the applicant/beneficiary responds "yes" to fewer than three of the four questionslisted above, or if the applicant/beneficiary does not know the scope of coverage,enter the following post payment recovery codes:

(3)

A Other Coverage code for any insurance company;

M Multiple coverage; beneficiary has more than one insurancecompany (use only when companies are Identified as post paymentrecovery codes).

BLUE SHIELDX

Z BLUE CROSS

Multiple Cost Avoidance or PHP/HMO/CMP Other Health Coverage:

If an applicant/beneficiary has multiple (two or more) full coverage policies, one ofwhich is a PHP/HMO/CMP, use the appropriate PHP/HMO/CMP code (K, C, P, orF). Otherwise, assign the appropriate cost avoidance code for the carrier thatprovides the most comprehensive coverage.

(4)

SECTION NO.: 50769 MANUAL LETTER NO.: 155 DATE: 1-16-96 1SA-15

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(5) Dental OHC Code:

If the applicant/beneficiary responds *"no to all four questions listed above, ask ifhe/she has an insurance policy for dental only coverage. If the applicant/beneficiaryresponds "yes" to having dental only coverage and he/she does not have any otherhealth insurance policy, enter the cost avoidance code “L" (Dental Only Policies) onMEDS.

Scope of Coverage

Upon receipt of a Health Insurance Questionnaire (DHS 6155, revision date 2/90 or later), theDepartment enters insurance billing information and scope of coverage codes onto the HealthInsurance System (HIS). This information Is printed on Medi-Cal cards. The scope of coverageinformation assists providers in determining which services must be billed to the beneficiary’sinsurance. The scope of coverage codes are as follows:

I - Hospital Inpatient CareO - Hospital Outpatient CareM - Medical/Doctor’s VisitsP - Prescription DrugsL - Long Term CareV - Vision CareD - Dental Care

When an EW initially assigns a post payment recovery code on the MEDS, the Department will changeit to a cost avoidance code upon receiving the DHS 6155 and enter the scope of coverage codes onHIS. Replacement of the post payment recovery code with a cost avoidance code when scope ofcoverage has been entered is a correct procedure. Counties are not to change the cost avoidancecode back to the original post payment recovery code.

If Medi-Cal beneficiaries have health insurance, but the Medi-Cal program has not yet receivedinformation about the Insurance coverage, the word "COMPREHENSIVE” will appear on Medi-Calcards instead of scope of coverage codes. This designation “COMPREHENSIVE" alerts providers tobill the other health insurance for all services provided.

When a change to the scope of coverage, policy number, or insurance billing information is necessary,request corrections by either submitting a corrected DHS 6155 or calling the Department’s HealthInsurance Section at 1-800-952-5294.

Current and/or Prior Month Changes to Other Health Coverage Codes

a. Current and/or Prior Month Changes for New Eligibles:

If beneficiaries are initially eligible for Medi-Cal and are reported with a cost avoided insurancepolicy, counties may enter a cost avoidance code for current and/or prior months.

SECTION NO.: 50769 MANUAL LETTER NO.: 155 DATE: 1 — 16 — 96 15A-16


b. Current and/or Prior Month Changes for Ongoing Cases:

No cost avoidance Other Health Coverage (OHC) codes may be assigned to current and/orprior months for ongoing cases. The message M373 "ONLY PAY AND CHASE (POSTPAYMENT RECOVERY) OTHER-COV ALLOWED WHEN ELIGIBLE ON MEDS" will appearwhen EWs attempt to enter a cost avoidance OHC code to current and/or prior months fora beneficiary who is already MEDS eligible.

If an ongoing eligible has been Identified with unreported OHC which is currently available orwas available at any time during MEDS' history months, assign the post payment recoverycode "A" for the current and prior months and use the appropriate OHC code for the pendingmonth. Send a completed Health Insurance Questionnaire (DHS 6155, revision date 2/90 orlater) to the Department. It is very important for EWs to make sure the insurance policy startdate is included on the DHS 6155 because the retroactive post payment recovery processenables the Department to bill the insurance carrier for services already received.

The following illustrates the propriety of various OHC code changes for current and/or priormonths:

PERMISSIBLE CHANGES

Cost Avoidance Code

Cost Avoidance OR PostPayment Recovery Code

TO

TO

Post Payment Recovery Code

No Other HealthCoverage Code (N)Post Payment Recovery CodeNo Other Health Coverage (N) TO

PROHIBITED CHANGES

No Other Health Coverage (N) TO Cost Avoidance CodePost Payment Recovery Code TO Cost Avoidance CodeCost Avoidance Code TO A Different Cost Avoidance Code

Medi-Cal Eligibility Data System On-Line Other Health Coverage Code Override Process

a. County-Controlled Cases:

10.

To change the Other Health Coverage (OHC) code to cost avoidance for the future month oncounty-controlled cases, report the proper cost avoidance code by using an EW20 or EW30.

If a corrected Medi-Cal card is required for a current and/or prior months, use an EW15 tochange the OHC code to a post payment recovery code "A" and Issue the corrected Medi-Calcard(s).

When making on-line changes to OHC codes, always send in a Health InsuranceQuestionnaire (DHS 6155, revision date 2/90 or later) containing the old insurance policyinformation to the Department (include termination date of the policy). Submit anotherDHS 6155 containing the new Insurance policy Information (include the start date and scopeof coverage of the policy).

SECTION NO.: 50769 MANUAL LETTER NO.: 155 DATE: 1-16—96 15A-17


b. Supplemental Security Income/State Supplemental Payment Cases:

To change the OHC code to cost avoidance for the future month on Supplemental SecurityIncome/State Supplemental Payment (SSI/SSP) cases, report the proper cost avoidancecode for the future month by submitting a completed DHS 6155 to the Department. TheDepartment will assign the proper cost avoidance code and scope of coverage. Submitanother DHS 6155 containing the old insurance information (include termination date of thepolicy).

If a corrected Medi-Cal card Is required for a current and/or prior months, use EW55 tochange the OHC code to a post payment recovery code “A" and issue the correctedMedi-Cal card(s).

When making on-line changes to OHC codes, always send in two DHS 6155s, one containingthe old insurance policy information (including the policy's termination date) and the othercontaining the new insurance policy information.

Be aware that changing the OHC code will delete scope of coverage and health insuranceinformation on the Medi-Cal card. This safety measure is intended to prevent the possibilityof the insurance information falling to match the new OHC value.

Replacement Card Issuance With Corrected Scope of Coverage Codes

EWs must issue replacement Medi-Cal cards for both county-controlled and SSI/SSP eligible caseswhen the OHC code is in error. If a beneficiary needs an IMMEDIATE NEED CARD only because theOHC code is incorrect, follow the on-line Instructions described in Section 15A (10. MEDS On-LineOther Health Coverage Code Override Process). If the beneficiary needs an IMMEDIATE NEED CARDbecause the scope of coverage coding is Incorrect, proceed as follows:

11.

• If the beneficiary can wait a few days for a card, call the Health Insurance Section at1-800-952-5294 and request a change to the scope of coverage coding on the HealthInsurance System (HIS). Allowing one day for the HIS update, request a Medi Cal card thenext day using the EW45.

• if the beneficiary needs a card the same day, use the EW15 or EW 55 transaction to changethe OHC code to an "A" and to issue a Medi-Cal card. This action will suspend HIS so that NOscope of coverage or health insurance is displayed on the IMMEDIATE NEED CARD, in orderto report the proper cost avoidance code for the future month on county-controlled cases, initiate an OHC code change using the EW20 or EW30 and send a completed HealthInsurance Questionnaire (DHS 6155, revision date 2/90 or later) containing the correctedscope of coverage to the Department. For SSI/SSP cases, send a completed DHS 6155 tothe Department The Department wil assign the proper cost avoidance code and update HISwith the corrected scope of coverage.

SECTION NO.: 50769 MANUAL LETTER NO.: 15 5 DATE: 1-16-96 15A-18


12.Beneficiary and County Welfare Department Inquiries Regarding Other Health Coverage

Other Health Coverage questions can be answered between 8:00 a.m. and 5:00 p.m., Monday throughFriday, by calling the Health Insurance Section’s toll-free number, 1-800-952-5294. Spanish speakingoperators are also available from 8:00 a.m. to 5:00 p.m., Monday through Friday. Eligibility Workersmay give this toll-free number to beneficiaries with the understanding that only health Insurance relatedquestions can be answered.



15H-HEALTH INSURANCE PREMIUM PAYMENT PROGRAM

This section provides background information and procedures pertaining to the Health Insurance PremiumPayment (HIPP) and Employer Group Health Plan (EGHP) Programs.

1. Program Background

The HIPP Program (Welfare and Institutions Code, Section 14124.91) was established by enactment of Assembly Bill 3328 (Margolin, Chapter 940, Statutes of 1986). This law authorizesthe Department of Health Services (DHS), whenever it is cost effective, to pay health coveragepremiums on behalf of Medi-Cal beneficiaries. Cost effectiveness is defined by Section 50778,California Code of Regulations (CCR) as when the annual cost of the premium is less than half theestimated cost of Medi-Cal benefits. The primary objective of the Program is to continue ahigh-cost Medi-Cal beneficiary’s other health coverage by paying medical coverage premiums forthe beneficiary. Paying premiums for high-cost medical results in a reduction of Medi-Cal costs.

The EGHP Program (Section 4402, Omnibus Budget Reconciliation Act of 1990 (OBRA ’90))mandates (effective January 1, 1991), that all states, when it is cost effective, pay the healthinsurance premiums, deductibles, co-payment and other cost-sharing obligations for Medi-Calrecipients eligible for enrollment in an employer group health plan. The State may also pay thepremiums (but not other cost-sharing obligations) for a non-Medi-Cal eligible if the Medi-Caleligible's enrollment in the health plan is dependent on the non-Medi-Cal eligible's enrollment. Inaddition, OBRA '90 mandates that when it is cost effective, enrollment in an employer or grouphealth plan is a condition of Medicaid eligibility except for an individual (such as a child) who isunable to enroll on his/her own behalf.

To participate in the HIPP and EGHP Programs, applicants will have to prove that their monthlymedical costs are at least twice as much as the monthly insurance premiums.

2. HIPP/EGHP Qualifying_Criteria

a. The applicant must currently be on Medi-Cal.

b. The Medi-Cal Share of Cost, if any, must be $200 or less.

c. There is a expensive medical condition. The average monthly savings to Medi-Cal fromthe health insurance must be at least twice the monthly insurance premiums. The monthlyShare of Cost will be subtracted from the monthly health care costs to determine if payingthe premiums is cost effective.

d. There is a current health insurance policy, COBRA continuation policy, or a COBRAconversion policy in effect, or an employer group health plan for which enrollmentapplication has not been made, but which is available to the beneficiary.

e. The application must be completed and returned in time for the State to process theapplication and pay the premium.

f. The health insurance policy must cover the high cost medical condition.

SECTION NO.: 50778 MANUAL LETTER NO.: 155 DATE: 1-16-96 15H-1


g. The policy must not be issued through the California Major Risk Medical Insurance Board(MRMIB).

h. There is no enrollment in a Medi-Cal related prepaid health plan, County Health Initiative,Geographic Managed Care, or the County Medical Services Program (CMSP).

i. The premiums are not the responsibility of an absent parent.

CountyResponsibilities3.

In order to identify Medi-Cal applicants/beneficiaries who are potentially eligible for the HIPP/EGHPPrograms, county workers must:

a. Issue a Health Insurance Questionnaire (DHS 6155-Revised 10/90) form to the beneficiaryto complete during the application and redetermination processes when theapplicant/beneficiary indicates: 1) that he/she or a family member is employed and thatemployer-related health insurance is available but has not been applied for, 2) that he/sheor a family member currently has individual, group or employer-related health insuranceand has a high cost medical condition.

(1) If the applicant/beneficiary currently has health insurance (private or employerrelated) AND a high cost medical condition.

(a) Complete the DHS 6155. Indicate the illness and the name of theapplicant/beneficiary with the illness in the #9 area of the form. In theupper right hand corner of the DHS 6155 form, write the notation "HIPP".

(2) If the applicant/beneficiary is not covered by a health plan, but has a high costmedical condition, AND health insurance is available through an employer (orfamily member's employer), but the applicant/beneficiary has not enrolled:

(a) Complete the DHS 6155. Indicate the illness, and the name of theapplicant/beneficiary with the illness in the #9 area of the form. Also,indicate the name(s) and Social Security Number(s) of beneficiaries whocould be enrolled, the name/address of the employer, the name of theavailable health insurance, and the name and Social Security Number ofthe employee who has the insurance available to him/her. Check the #6box "Medical coverage available through employer, but has not beenapplied for". In the upper right hand corner of the DHS 6155 form, writethe notation "EGHP REFERRAL ONLY". This indicates that theapplicant(s)/beneficary(s) listed do not currently have the insurance andyou are completing an EGHP referral so that DHS can determine if itwould be cost effective to purchase the employer-related health insurancefor the applicant/beneficiary with a high cost medical condition.


MEDI-CAL ELIGIBILITY PROCEDURES MANUAL...

(3) If insurance is available through an employer (or family member’s employer), buthas not been enrolled in and no one in the case has a high cost medical condition.

(a) Complete the DHS 6155. Indicate the name(s) and Social SecurityNumber(s) of beneficiaries who could be enrolled, the name/address of theemployer, the name of the available health insurance, and the name andSocial Security Number of the employee who has the insurance availableto him/her. Check the #6 box "Medical coverage available throughemployer, but has not been applied for”. In the upper right hand cornerof the DHS 6155 form, write the notation "EGHP REFERRAL ONLY”. Thisindicates that the applicant(s)/beneficiary(s) listed do not currently havethe insurance and you are completing an EGHP referral so that DHS candetermine if it would be cost effective to purchase the employer-relatedhealth insurance.

b. Assure that critical segments of the DHS 6155 (applicant/beneficiary name, Medi-Calidentification number, applicant/beneficiary telephone number, insurance carrier name,union/employer name and telephone number) are complete, accurate, and readable.

SPECIAL NOTE: If the beneficiary cannot be given the form in person and the beneficiary notifiesthe CWD that his/her health insurance has or is about to terminate, or the beneficiary has notapplied for employer-related health insurance, the Eligibility Worker (EW) must send the HealthInsurance Questionnaire (DHS 6155) form to the beneficiary to complete, sign, and date.Instructions must be given to the beneficiary to mail the form to the DHS.

c. Advise the applicant/beneficiary that providing the health insurance information will notinterfere with Medi-Cal eligibility, but if payment for the group or employer-related health insurance plan is approved by the Department, enrollment in the health plan is mandatory.Disenrollment from the plan by the applicant/beneficiary, without the approval ofDepartment of Health Services, is cause for discontinuance of Medi-Cal eligibility.

d. Advise the applicant/beneficiary that if health insurance coverage is available from anysource, (i.e., employer, union), at no cost to the beneficiary, the applicant/beneficiary mustenroll. If the applicant/beneficiary fails to cooperate by not enrolling in the plan, thecounty worker must deny or discontinue Medi-Cal eligibility.

e. Retain a copy of the Health Insurance Questionnaire (DHS 6155) in the case file.

f. Mail the completed Health Insurance Questionnaire (DHS 6155) within five (5) days to theDepartment of Health Services. Send the HIPP or EGHP DHS 6155 application form in aseparate envelope from all other DHS 6155 forms to:

Department of Health ServicesMedi-Cal Third Party Liability Branch

HIPP/EGHPP.O. Box 1287

Sacramento, CA 95812-1287



g. Notify the Department immediately by calling (916) 323-5339 if the County determinesthat a beneficiary has withdrawn from enrollment in a plan for which DHS pays premiumsunder HIPP or EGHP. The Department will direct the County by letter to discontinueMedi-Cal eligibility upon verification of the beneficiary's disenrollment from the plan. TheCounty must notify the beneficiary that eligibility has been withdrawn in accordance withSection 50179 (c) (7), Title 22, CCR, when instructed by the Department to discontinueMedi-Cal eligibility.

h. Review and recompute the beneficiary's Share of Cost as necessary in accordance withArticles 12A and 12B (Share of Cost) of the procedures portion of the Medi-Cal EligibilityManual.

Utilizing the HIPP/EGHP qualifying criteria the Department shall:

a. Review the Health Insurance Questionnaire (DHS 6155), contact applicant/beneficiary foradditional documentation and approve the application when it is determined to be costeffective for the State to pay the health insurance premiums.

b. Notify the County and the beneficiary of State’s intent to approve and/or terminatepayment of the health insurance coverage.


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